Associations of substance use, psychosis, and mortality among people living in precarious housing or homelessness: A longitudinal, community-based study in Vancouver, Canada


Autoři: Andrea A. Jones aff001;  Kristina M. Gicas aff001;  Sam Seyedin aff001;  Taylor S. Willi aff001;  Olga Leonova aff001;  Fidel Vila-Rodriguez aff001;  Ric M. Procyshyn aff001;  Geoffrey N. Smith aff001;  Toby A. Schmitt aff001;  A. Talia Vertinsky aff002;  Tari Buchanan aff001;  Alex Rauscher aff003;  Donna J. Lang aff002;  G. William MacEwan aff001;  Viviane D. Lima aff004;  Julio S. G. Montaner aff004;  William J. Panenka aff001;  Alasdair M. Barr aff005;  Allen E. Thornton aff006;  William G. Honer aff001
Působiště autorů: Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada aff001;  Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada aff002;  Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada aff003;  Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada aff004;  Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada aff005;  Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada aff006
Vyšlo v časopise: Associations of substance use, psychosis, and mortality among people living in precarious housing or homelessness: A longitudinal, community-based study in Vancouver, Canada. PLoS Med 17(7): e1003172. doi:10.1371/journal.pmed.1003172
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003172

Souhrn

Background

The “trimorbidity” of substance use disorder and mental and physical illness is associated with living in precarious housing or homelessness. The extent to which substance use increases risk of psychosis and both contribute to mortality needs investigation in longitudinal studies.

Methods and findings

A community-based sample of 437 adults (330 men, mean [SD] age 40.6 [11.2] years) living in Vancouver, Canada, completed baseline assessments between November 2008 and October 2015. Follow-up was monthly for a median 6.3 years (interquartile range 3.1–8.6). Use of tobacco, alcohol, cannabis, cocaine, methamphetamine, and opioids was assessed by interview and urine drug screen; severity of psychosis was also assessed. Mortality (up to November 15, 2018) was assessed from coroner’s reports and hospital records. Using data from monthly visits (mean 9.8, SD 3.6) over the first year after study entry, mixed-effects logistic regression analysis examined relationships between risk factors and psychotic features. A past history of psychotic disorder was common (60.9%). Nonprescribed substance use included tobacco (89.0%), alcohol (77.5%), cocaine (73.2%), cannabis (72.8%), opioids (51.0%), and methamphetamine (46.5%). During the same year, 79.3% of participants reported psychotic features at least once. Greater risk was associated with number of days using methamphetamine (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.05–1.24, p = 0.001), alcohol (aOR 1.09, 95% CI 1.01–1.18, p = 0.04), and cannabis (aOR 1.08, 95% CI 1.02–1.14, p = 0.008), adjusted for demographic factors and history of past psychotic disorder. Greater exposure to concurrent month trauma was associated with increased odds of psychosis (adjusted model aOR 1.54, 95% CI 1.19–2.00, p = 0.001). There was no evidence for interactions or reverse associations between psychotic features and time-varying risk factors. During 2,481 total person years of observation, 79 participants died (18.1%). Causes of death were physical illness (40.5%), accidental overdose (35.4%), trauma (5.1%), suicide (1.3%), and unknown (17.7%). A multivariable Cox proportional hazard model indicated baseline alcohol dependence (adjusted hazard ratio [aHR] 1.83, 95% CI 1.09–3.07, p = 0.02), and evidence of hepatic fibrosis (aHR 1.81, 95% CI 1.08–3.03, p = 0.02) were risk factors for mortality. Among those under age 55 years, a history of a psychotic disorder was a risk factor for mortality (aHR 2.38, 95% CI 1.03–5.51, p = 0.04, adjusted for alcohol dependence at baseline, human immunodeficiency virus [HIV], and hepatic fibrosis). The primary study limitation concerns generalizability: conclusions from a community-based, diagnostically heterogeneous sample may not apply to specific diagnostic groups in a clinical setting. Because one-third of participants grew up in foster care or were adopted, useful family history information was not obtainable.

Conclusions

In this study, we found methamphetamine, alcohol, and cannabis use were associated with higher risk for psychotic features, as were a past history of psychotic disorder, and experiencing traumatic events. We found that alcohol dependence, hepatic fibrosis, and, only among participants <55 years of age, history of a psychotic disorder were associated with greater risk for mortality. Modifiable risk factors in people living in precarious housing or homelessness can be a focus for interventions.

Klíčová slova:

Alcoholism – Cannabis – Cocaine – Housing – Medical risk factors – Psychoses – Traumatic brain injury – Traumatic injury risk factors


Zdroje

1. Hwang SW, Wilkins R, Tjepkema M, O'Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. Brit Med J. 2009;339:1068–70. doi: 10.1136/bmj.b4036 19858533

2. Nielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M. Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study. Lancet. 2011;377:2205–14. doi: 10.1016/S0140-6736(11)60747-2 21676456

3. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384:1529–40. doi: 10.1016/S0140-6736(14)61132-6 25390578

4. Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018;391:241–50. doi: 10.1016/S0140-6736(17)31869-X 29137869

5. Luchenski S, Maguire N, Aldridge RW, Hayward A, Story A, Perri P, et al. What works in inclusion health: overview of effective interventions for marginalised and excluded populations. Lancet. 2018;391:266–80. doi: 10.1016/S0140-6736(17)31959-1 29137868

6. Starzer MSK, Nordentoft M, Hjorthøj C. Rates and predictors of conversion to schizophrenia or bipolar disorder following substance-induced psychosis. Am J Psychiatry. 2018;175:343–50. doi: 10.1176/appi.ajp.2017.17020223 29179576

7. Kendler KS, Ohlsson H, Sundquist J, Sundquist K. Prediction of onset of substance-induced psychotic disorder and its progression to schizophrenia in a Swedish national sample. Am J Psychiatry. 2019;176:711–719. doi: 10.1176/appi.ajp.2019.18101217 31055966

8. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.

9. Hui CLM, Honer WG, Chang WC, Chen ESM, Lui SSY, Jones PB, et al. Long-term effects of discontinuation from antipsychotic maintenance following first-episode schizophrenia and related disorders: a 10 year follow-up of a randomised, double-blind trial. Lancet Psychiatry. 2018;5:432–42. doi: 10.1016/S2215-0366(18)30090-7 29551618

10. Chen EYH, Hui CLM, Lam MML, Chiu CPY, Law CW, Chung DWS, et al. Maintenance treatment with quetiapine versus discontinuation after one year of treatment in patients with remitted first episode psychosis: randomised controlled trial. Brit Med J. 2010;341:c4024–4. doi: 10.1136/bmj.c4024 20724402

11. Vaughn CE, Snyder KS, Jones S, Freeman WB, Falloon IR. Family factors in schizophrenic relapse. Arch Gen Psychiatry. 1984;41:1169–77. doi: 10.1001/archpsyc.1984.01790230055009 6150694

12. Landin-Romero R, McKenna PJ, Romaguera A, Álvarez-Moya E, Sarró S, Aguirre C, et al. Examining the continuum of psychosis: Frequency and characteristics of psychotic-like symptoms in relatives and non-relatives of patients with schizophrenia. Schizophr Res. 2016;178:6–11. doi: 10.1016/j.schres.2016.07.015 27632907

13. Kendler KS, Gallagher TJ, Abelson JM, Kessler RC. Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample—The National Comorbidity Survey. Arch Gen Psychiatry. 1996;53:1022–31. doi: 10.1001/archpsyc.1996.01830110060007 8911225

14. Lieberman JA, First MB. Psychotic disorders. N Engl J Med. 2018;379:270–80. doi: 10.1056/NEJMra1801490 30021088

15. Glasner-Edwards S, Mooney LJ. Methamphetamine psychosis: epidemiology and management. CNS Drugs. 2014;28:1115–26. doi: 10.1007/s40263-014-0209-8 25373627

16. Vorspan F, Brousse G, Bloch V, Bellais L, Romo L, Guillem E, et al. Cocaine-induced psychotic symptoms in French cocaine addicts. Psychiatry Res. 2012;200:1074–6. doi: 10.1016/j.psychres.2012.04.008 22551940

17. Murray RM, Englund A, Abi-Dargham A, Lewis DA, Di Forti M, Davies C, et al. Cannabis-associated psychosis: neural substrate and clinical impact. Neuropharmacol. 2017;124:89–104. doi: 10.1016/j.neuropharm.2017.06.018 28634109

18. Jordaan GP, Emsley R. Alcohol-induced psychotic disorder: a review. Metab Brain Dis. 2014;29:231–43. doi: 10.1007/s11011-013-9457-4 24307180

19. McKetin R, Lubman DI, Baker AL, Dawe S, Ali RL. Dose-related psychotic symptoms in chronic methamphetamine users: evidence from a prospective longitudinal study. JAMA Psychiatry. 2013;70:319–24. doi: 10.1001/jamapsychiatry.2013.283 23303471

20. Willi TS, Honer WG, Thornton AE, Gicas K, Procyshyn RM, Vila-Rodriguez F, et al. Factors affecting severity of positive and negative symptoms of psychosis in a polysubstance using population with psychostimulant dependence. Psychiatry Res. 2016;240:336–42. doi: 10.1016/j.psychres.2016.04.059 27138828

21. Howes OD, Murray RM. Schizophrenia: an integrated sociodevelopmental-cognitive model. Lancet. 2014;383:1677–87. doi: 10.1016/S0140-6736(13)62036-X 24315522

22. Zammit S, Lewis G, Dalman C, Allebeck P. Examining interactions between risk factors for psychosis. Brit J Psychiatry. 2010;197:207–11. doi: 10.1192/bjp.bp.109.070904 20807965

23. Vila-Rodriguez F, Panenka WJ, Lang DJ, Thornton AE, Vertinsky AT, Wong H, et al. The Hotel study: multimorbidity in a community sample living in marginal housing. Am J Psychiatry. 2013;170:1413–22. doi: 10.1176/appi.ajp.2013.12111439 23929175

24. Knight KR, Lopez AM, Comfort M, Shumway M, Cohen J, Riley ED. Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space. Int J Drug Policy. 2014;25:556–61. doi: 10.1016/j.drugpo.2013.10.011 24411945

25. Hwang SW, Colantonio A, Chiu S, Tolomiczenko G, Kiss A, Cowan L, et al. The effect of traumatic brain injury on the health of homeless people. Can Med Assoc J. 2008;179:779–84. doi: 10.1503/cmaj.080341 18838453

26. Schmitt T, Thornton AE, Rawtaer I, Barr AM, Gicas KM, Lang DJ, et al. Traumatic brain injury in a community-based cohort of homeless and vulnerably housed individuals. J Neurotrauma. 2017;34:3301–10. doi: 10.1089/neu.2017.5076 28741437

27. Trotta A, Murray RM, Fisher HL. The impact of childhood adversity on the persistence of psychotic symptoms: a systematic review and meta-analysis. Psychol Med. 2015;45:2481–98. doi: 10.1017/S0033291715000574 25903153

28. Mansueto G, Faravelli C. Recent life events and psychosis: the role of childhood adversities. Psychiatry Res. 2017;256:111–7. doi: 10.1016/j.psychres.2017.06.042 28628791

29. Lataster J, Myin-Germeys I, Lieb R, Wittchen HU, van Os J. Adversity and psychosis: a 10-year prospective study investigating synergism between early and recent adversity in psychosis. Acta Psychiat Scand. 2012;125:388–99. doi: 10.1111/j.1600-0447.2011.01805.x 22128839

30. Stubbs JL, Thornton AE, Sevick JM, Silverberg ND, Barr AM, Honer WG, et al. Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis. Lancet Public Health. 2020;5:e19–e32. doi: 10.1016/S2468-2667(19)30188-4 31806487

31. Sachdev P, Smith JS, Cathcart S. Schizophrenia-like psychosis following traumatic brain injury: a chart-based descriptive and case-control study. Psychol Med. 2001;31:231–9. doi: 10.1017/s0033291701003336 11232911

32. Olfson M, Lewis-Fernandez R, Weissman MM, Feder A, Gameroff MJ, Pilowsky D, et al. Psychotic symptoms in an urban general medicine practice. Am J Psychiatry. 2002;159:1412–9. doi: 10.1176/appi.ajp.159.8.1412 12153836

33. Fazel S, Khosla V, Khosla V, Doll H, Doll H, Geddes J, et al. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5:e225. doi: 10.1371/journal.pmed.0050225 19053169

34. Honer WG, Cervantes-Larios A, Jones AA, Vila-Rodriguez F, Montaner JS, Tran H, et al. The Hotel study-clinical and health service effectiveness in a cohort of homeless or marginally housed persons. Can J Psychiatry. 2017;62:482–92. doi: 10.1177/0706743717693781 28199798

35. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72:334–41. doi: 10.1001/jamapsychiatry.2014.2502 25671328

36. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease study 2010. Lancet. 2013;382:1575–86. doi: 10.1016/S0140-6736(13)61611-6 23993280

37. Olfson M, Gerhard T, Huang C, Crystal S, Stroup TS. Premature mortality among adults with schizophrenia in the United States. JAMA Psychiatry. 2015;72:1172–81. doi: 10.1001/jamapsychiatry.2015.1737 26509694

38. Jones AA, Vila-Rodriguez F, Leonova O, Langheimer V, Lang DJ, Barr AM, et al. Mortality from treatable illnesses in marginally housed adults: a prospective cohort study. BMJ Open. 2015;5: e008876. doi: 10.1136/bmjopen-2015-008876 26297373

39. Barbic SP, Jones AA, Woodward M, Piercy M, Mathias S, Vila-Rodriguez F, et al. Clinical and functional characteristics of young adults living in single room occupancy housing: preliminary findings from a 10-year longitudinal study. Can J Pub Health. 2018;109: 204–214. doi: 10.17269/s41997-018-0087-9 29981045

40. Gaetz S, Barr C, Friesen A, Harris B, Hill C, Kovacs-Burns K, et al. Canadian definition of homelessness. Canadian Observatory on Homelessness, Toronto [Internet]. 2012 [cited 2019 May 24]. Available from: https://www.homelesshub.ca/sites/default/files/COHhomelessdefinition.pdf.

41. Amorim P, Lecrubier Y, Weiller E, Hergueta T, Sheehan D. DSM-III-R Psychotic Disorders: procedural validity of the Mini International Neuropsychiatric Interview (MINI). Eur Psychiatry. 1998;13:26–34. doi: 10.1016/S0924-9338(97)86748-X 19698595

42. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bull. 1987;13:261–76. doi: 10.1093/schbul/13.2.261 3616518

43. Goodman SH, Sewell DR, Cooley EL, Leavitt N. Assessing levels of adaptive functioning: the Role Functioning Scale. Comm Ment Health J. 1993;29:119–31. doi: 10.1007/BF00756338 8500285

44. Mueser KT, Salyers MP, Rosenberg SD, Ford JD, Fox L, Carty P. Psychometric evaluation of trauma and posttraumatic stress disorder assessments in persons with severe mental illness. Psychol Assess. 2001;13:110–7. doi: 10.1037//1040-3590.13.1.110 11281032

45. Hooper LM, Stockton P, Krupnick JL, Green BL. Development, use, and psychometric properties of the Trauma History Questionnaire. J Loss Trauma. 2011;16:258–83.

46. Sacks JAY, Drake RE, Williams VF, Banks SM, Herrell JM. Utility of the Time-Line Follow-Back to assess substance use among homeless adults. J Nerv Ment Dis. 2003;191:145–53. doi: 10.1097/01.NMD.0000054930.03048.64 12637840

47. Procyshyn RM, Bezchlibnyk-Butler KZ, Jeffries JJ. Clinical Handbook of Psychotropic Drugs. Boston, MA: Hogrefe Publishing; 2017.

48. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. Arch Gen Psychiatry. 1988;45:789–96. doi: 10.1001/archpsyc.1988.01800330013001 3046553

49. Narrow WE, Clarke DE, Kuramoto SJ, Kraemer HC, Kupfer DJ, Greiner L, et al. DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5. Am J Psychiatry. 2013;170:71–82. doi: 10.1176/appi.ajp.2012.12071000 23111499

50. Bolker BM, Brooks ME, Clark CJ, Geange SW, Poulsen JR, Stevens MHH, et al. Generalized linear mixed models: a practical guide for ecology and evolution. Trends Ecol Evol. 2009;24:127–35. doi: 10.1016/j.tree.2008.10.008 19185386

51. Deans GD, Raffa JD, Lai C, Fischer B, Krajden M, Amin J, et al. Mortality in a large community-based cohort of inner-city residents in Vancouver, Canada. Can Med J Open. 2013;1:E68–76. doi: 10.9778/cmajo.20130002 25077106

52. Gicas KM, Jones AA, Thornton AE, Petersson A, Livingston E, Waclawik K, et al. Cognitive decline and mortality in a community-based sample of homeless and precariously housed adults: 9-year prospective study. Br J Psychiatry Open. 2020;6: e21. doi: 10.1192/bjo.2020.3 32043436

53. Connell PH. Amphetamine Psychosis. Maudsley Monograph. London: Chapman & Hall; 1958.

54. Panenka WJ, Procyshyn RM, Lecomte T, MacEwan GW, Flynn SW, Honer WG, et al. Methamphetamine use: a comprehensive review of molecular, preclinical and clinical findings. Drug Alc Depend. 2013;129:167–79. doi: 10.1016/j.drugalcdep.2012.11.016 23273775

55. Arunogiri S, Foulds JA, McKetin R, Lubman DI. A systematic review of risk factors for methamphetamine-associated psychosis. Aust NZ J Psychiatry. 2018;52:514–29. doi: 10.1177/0004867417748750 29338289

56. Glass IB. Alcoholic hallucinosis: a psychiatric enigma –1. The development of an idea. Br J Addict. 1989;84: 29–41. doi: 10.1111/j.1360-0443.1989.tb00549.x 2644996

57. Glass IB. Alcoholic hallucinosis: a psychiatric enigma– 2. Follow-up studies. Br J Addict. 1989;84: 151–164. doi: 10.1111/j.1360-0443.1989.tb00564.x 2655768

58. Voce A, Calabria B, Burns R, Castle D, McKetin R. A systematic review of the symptom profile and course of methamphetamine-associated psychosis. Subst Use Misuse. 2019;54:549–59. doi: 10.1080/10826084.2018.1521430 30693832

59. Perälä J, Kuoppasalmi K, Pirkola S, Härkänen T, Saarni S, Tuulio-Henriksson A, et al. Alcohol-induced psychotic disorder and delirium in the general population. Brit J Psychiatry. 2010;197:200–6. doi: 10.1192/bjp.bp.109.070797 20807964

60. Vallersnes OM, Dines AM, Wood DM, Yates C, Heyerdahl F, Hovda KE, et al. Psychosis associated with acute recreational drug toxicity: a European case series. BMC Psychiatry. 2016;16:293. doi: 10.1186/s12888-016-1002-7 27538886

61. Solomons K, Neppe VM, Kuyl JM. Toxic cannabis psychosis is a valid entity. S Afr Med J. 1990;78:476–81. 2218786

62. Honer WG, Gewirtz G, Turey M. Psychosis and violence in cocaine smokers. Lancet. 1987;2: 451. doi: 10.1016/s0140-6736(87)90982-2 2887748

63. Kalayasiri R, Sughondhabirom A, Gueorguieva R, Coric V, Lynch WJ, Morgan PT, et al. Self-reported paranoia during laboratory “binge” cocaine self-administration in humans. Pharmacol Biochem Behav. 2006;83:249–56. doi: 10.1016/j.pbb.2006.02.005 16549106

64. Alexander PD, Gicas KM, Willi TS, Kim CN, Boyeva V, Procyshyn RM, et al. A comparison of psychotic symptoms in subjects with methamphetamine versus cocaine dependence. Psychopharmacol. 2017;234:1535–47. doi: 10.1007/s00213-017-4551-7 28190084

65. Hwang SW, Aubry T, Palepu A, Farrell S, Nisenbaum R, Hubley AM, et al. The health and housing in transition study: a longitudinal study of the health of homeless and vulnerably housed adults in three Canadian cities. Int J Public Health. 2011;56: 609–623. doi: 10.1007/s00038-011-0283-3 21858461

66. Lewis M, Boyes K, McClanahan D, Copas J. Downtown Eastside demographic study of SRO and social housing tenants. Vancouver: City of Vancouver [Internet]; 2008 Jun [cited 2016 Mar 27]. Available from: https://www.vancouveragreement.ca/wp-content/uploads/080600_DTES-Demographic-Study-Final.pdf.

67. Shannon K, Ishida T, Lai C, Tyndall MW. The impact of unregulated single room occupancy hotels on the health status of illicit drug users in Vancouver. Int J Drug Policy. 2006;17:107–114.

68. Palepu A, Gadermann A, Hubley AM, Farrell S, Gogosis E, Aubry T, et al. Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities. PLoS ONE. 2013;8: e75133. doi: 10.1371/journal.pone.0075133 24124470

69. Bousman CA, McKetin R, Burns R, Woods SP, Morgan EE, Atkinson JH, et al. Typologies of positive psychotic symptoms in methamphetamine dependence. Am J Addict. 2015;24:94–7. doi: 10.1111/ajad.12160 25864598

70. McKetin R, Baker AL, Dawe S, Voce A, Lubman DI. Differences in the symptom profile of methamphetamine-related psychosis and primary psychotic disorders. Psychiatry Res. 2017;251:349–54. doi: 10.1016/j.psychres.2017.02.028 28282630

71. McKetin R, Voce A, Burns R, Ali R, Lubman DI, Baker AL, et al. Latent psychotic symptom profiles amongst people who use methamphetamine: what do they tell us about existing diagnostic categories? Front Psychiatry. 2018;9:578. doi: 10.3389/fpsyt.2018.00578 30524318

72. Caton CLM, Hasin DS, Shrout PE, Drake RE, Dominguez B, First MB, et al. Stability of early-phase primary psychotic disorders with concurrent substance use and substance-induced psychosis. Brit J Psychiatry. 2007;190:105–11. doi: 10.1192/bjp.bp.105.015784 17267925

73. Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatry. 2005;162: 441–449. doi: 10.1176/appi.ajp.162.3.441 15741458

74. Howes OD, McCutcheon R, Agid O, de Bartolomeis A, van Beveren NJM, Birnbaum ML, et al. Treatment-resistant schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. Am J Psychiatry. 2017;174:216–229. doi: 10.1176/appi.ajp.2016.16050503 27919182


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